Pediatric Craniofacial Ballistic Injuries

Abstract

Pediatric ballistic injuries are a public health crisis in the United States. Younger children are more likely to sustain craniofacial injuries, which are associated with higher mortality rates. An understanding of the timeline of craniofacial development and the variation in pediatric facial proportions over time is important to guide further treatment of these patients. Management of these patients includes initial stabilization according to the Advanced Trauma Life Support protocol followed by management of time-sensitive injuries. Ballistic injuries often result in soft tissue and bone defects, requiring fixation and coverage. As children experience faster rates of bone healing, fixation should be done promptly. Soft tissue coverage is dependent on the size of the defect; whereas smaller wounds can be closed with primary closure or local tissue rearrangement, larger wounds may require free tissue transfer.

Keywords

pediatric ballistic injuries - pediatric craniofacial fractures - facial fractures - craniofacial development

Publication History

Article published online:
26 March 2025

• References

• 1 Andrews AL, Killings X, Oddo ER, Gastineau KAB, Hink AB. Pediatric firearm injury mortality epidemiology. Pediatrics 2022; 149 (03) e2021052739
• 2 Loder RT, Luster T. Fractures in children due to firearm activity. Children (Basel) 2023; 10 (04) 651
• 3 Hughes BD, Cummins CB, Shan Y, Mehta HB, Radhakrishnan RS, Bowen-Jallow KA. Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes. J Pediatr Surg 2020; 55 (08) 1596-1603
• 4 Roberts BK, Nofi CP, Cornell E, Kapoor S, Harrison L, Sathya C. Trends and disparities in firearm deaths among children. Pediatrics 2023; 152 (03) e2023061296
• 5 Dahlberg LL, Potter LB. Youth violence. Developmental pathways and prevention challenges. Am J Prev Med 2001; 20 (01) 3-14
• 6 Kalesan B, Vyliparambil MA, Bogue E. et al; Firearm Injury Research Group. Race and ethnicity, neighborhood poverty and pediatric firearm hospitalizations in the United States. Ann Epidemiol 2016; 26 (01) 1-6.e1 , 2
• 7 Naik-Mathuria BJ, Cain CM, Alore EA, Chen L, Pompeii LA. Defining the full spectrum of pediatric firearm injury and death in the United States: it is even worse than we think. Ann Surg 2023; 278 (01) 10-16
• 8 Grinshteyn E, Hemenway D. Violent death rates in the US compared to those of the other high-income countries, 2015. Prev Med 2019; 123: 20-26
• 9 Swendiman RA, Hatchimonji JS, Allukian III M, Blinman TA, Nance ML, Nace GW. Pediatric firearm injuries: anatomy of an epidemic. Surgery 2020; 168 (03) 381-384
• 10 Huelke DF. An overview of anatomical considerations of infants and children in the adult world of automobile safety design. Annu Proc Assoc Adv Automot Med 1998; 42: 93-113
• 11 Gajawelli N, Deoni S, Shi J. et al. Neurocranium thickness mapping in early childhood. Sci Rep 2020; 10 (01) 16651
• 12 Costello BJ, Rivera RD, Shand J, Mooney M. Growth and development considerations for craniomaxillofacial surgery. Oral Maxillofac Surg Clin North Am 2012; 24 (03) 377-396
• 13 Farkas LG, Posnick JC, Hreczko TM. Growth patterns of the face: a morphometric study. Cleft Palate Craniofac J 1992; 29 (04) 308-315
• 14 Scuderi AJ, Harnsberger HR, Boyer RS. Pneumatization of the paranasal sinuses: normal features of importance to the accurate interpretation of CT scans and MR images. AJR Am J Roentgenol 1993; 160 (05) 1101-1104
• 15 Lim RB, Hopper RA. Pediatric facial fractures. Semin Plast Surg 2021; 35 (04) 284-291
• 16 Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci 2014; 4 (01) 65-70
• 17 Adewale L. Anatomy and assessment of the pediatric airway. Paediatr Anaesth 2009; 19 (Suppl. 01) 1-8
• 18 McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment and management of pediatric trauma patients. Int J Crit Illn Inj Sci 2012; 2 (03) 121-127
• 19 Karam O, Russell RT, Stricker P. et al; Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI), Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Recommendations on RBC transfusion in critically ill children with nonlife-threatening bleeding or hemorrhagic shock from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018; 19 (9S, suppl 1): S127-S132
• 20 Gonzalez D, Bethencourt Mirabal A, McCall JD. Child Abuse and Neglect. . In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024 [Updated July 4, 2023. ]
• 21 Desai NM, Shah SU. Lateral Orbital Canthotomy. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024 [Updated July 25, 2023]
• 22 Phan LT, Jordan Piluek W, McCulley TJ. Orbital trapdoor fractures. Saudi J Ophthalmol 2012; 26 (03) 277-282
• 23 Brasileiro BF, Sickels JEV, Cunningham LL. Oculocardiac reflex in an adult with a trapdoor orbital floor fracture: case report, literature review, and differential diagnosis. J Korean Assoc Oral Maxillofac Surg 2020; 46 (06) 428-434
• 24 Ahmad Nasir S, Ramli R, Abd Jabar N. Predictors of enophthalmos among adult patients with pure orbital blowout fractures. PLoS One 2018; 13 (10) e0204946
• 25 Gupta G, Mahajan K. Nasal Septal Hematoma. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024 [Updated August 8, 2023]
• 26 Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl 2018; 100 (01) 6-11
• 27 Daghfous A, Bouzaïdi K, Abdelkefi M. et al. Contribution of imaging in the initial management of ballistic trauma. Diagn Interv Imaging 2015; 96 (01) 45-55
• 28 Alvis-Miranda HR, Adie Villafañe R, Rojas A, Alcala-Cerra G, Moscote-Salazar LR. Management of craniocerebral gunshot injuries: a review. Korean J Neurotrauma 2015; 11 (02) 35-43
• 29 Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock 2011; 4 (03) 395-402
• 30 Fountain AJ, Corey A, Malko JA, Strozier D, Allen JW. Imaging appearance of ballistic wounds predicts bullet composition: implications for MRI safety. AJR Am J Roentgenol 2021; 216 (02) 542-551
• 31 Ibraheem K, Wong S, Smith A. et al. Computed tomography angiography in the “no-zone” approach era for penetrating neck trauma: a systematic review. J Trauma Acute Care Surg 2020; 89 (06) 1233-1238
• 32 Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma 1969; 9 (12) 987-999
• 33 Hussain Zaidi SM, Ahmad R. Penetrating neck trauma: a case for conservative approach. Am J Otolaryngol 2011; 32 (06) 591-596
• 34 Ko JW, Gong SC, Kim MJ. et al. The efficacy of the “no zone” approach for the assessment of traumatic neck injury: a case-control study. Ann Surg Treat Res 2020; 99 (06) 352-361
• 35 Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma 2008; 64 (06) 1466-1471
• 36 Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence based review of the assessment and management of penetrating neck trauma. Clin Otolaryngol 2012; 37 (01) 44-52
• 37 Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg 2012; 99 (Suppl. 01) 149-154
• 38 Madiba TE, Muckart DJ. Penetrating injuries to the cervical oesophagus: is routine exploration mandatory?. Ann R Coll Surg Engl 2003; 85 (03) 162-166
• 39 Teehan EP, Padberg Jr. FT, Thompson PN. et al. Carotid arterial trauma: assessment with the Glasgow Coma Scale (GCS) as a guide to surgical management. Cardiovasc Surg 1997; 5 (02) 196-200
• 40 McNeil JD, Chiou AC, Gunlock MG, Grayson DE, Soares G, Hagino RT. Successful endovascular therapy of a penetrating zone III internal carotid injury. J Vasc Surg 2002; 36 (01) 187-190
• 41 Gönül E, Baysefer A, Kahraman S. et al. Causes of infections and management results in penetrating craniocerebral injuries. Neurosurg Rev 1997; 20 (03) 177-181
• 42 Argenta LC, Friedman RJ, Dingman RO, Duus EC. The versatility of pericranial flaps. Plast Reconstr Surg 1985; 76 (05) 695-702
• 43 Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: a review of the literature. J Emerg Trauma Shock 2015; 8 (04) 216-223
• 44 Hsieh PJ, Liao HT. Outcome analysis of surgical timing in pediatric orbital trapdoor fracture with different entrapment contents: a retrospective study. Children (Basel) 2022; 9 (03) 398
• 45 Oppenheimer AJ, Monson LA, Buchman SR. Pediatric orbital fractures. Craniomaxillofac Trauma Reconstr 2013; 6 (01) 9-20
• 46 Zeitoun IM, Ebeid K, Soliman AY. Growing skull fractures of the orbital roof: a multicentric experience with 28 patients. Childs Nerv Syst 2021; 37 (04) 1209-1217
• 47 Kaufman Y, Cole P, Hollier Jr LH. Facial gunshot wounds: trends in management. Craniomaxillofac Trauma Reconstr 2009; 2 (02) 85-90
• 48 Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 2001; 59 (03) 277-282
• 49 Volk AS, Shokri T, Sokoya M, Ducic Y, Hollier Jr LH. Facial gunshot wounds. Facial Plast Surg 2019; 35 (06) 578-583
• 50 Pontell ME, Niklinska EB, Braun SA, Jaeger N, Kelly KJ, Golinko MS. Resorbable versus titanium rigid fixation for pediatric mandibular fractures: a systematic review, institutional experience and comparative analysis. Craniomaxillofac Trauma Reconstr 2022; 15 (03) 189-200
• 51 Sharma S, Vashistha A, Chugh A. et al. Pediatric mandibular fractures: a review. Int J Clin Pediatr Dent 2009; 2 (02) 1-5
• 52 Cole P, Kaufman Y, Hollier Jr LH. Managing the pediatric facial fracture. Craniomaxillofac Trauma Reconstr 2009; 2 (02) 77-83
• 53 Lam S, Kuether J, Fong A, Reid R. Cranioplasty for large-sized calvarial defects in the pediatric population: a review. Craniomaxillofac Trauma Reconstr 2015; 8 (02) 159-170
• 54 Grant GA, Jolley M, Ellenbogen RG, Roberts TS, Gruss JR, Loeser JD. Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. J Neurosurg 2004; 100 (2, Suppl Pediatrics): 163-168
• 55 Singhal GD, Atri S, Suggala S, Jaluka D, Singhal S, Shrivastava AK. Growing skull fractures; pathogenesis and surgical outcome. Asian J Neurosurg 2021; 16 (03) 539-548
• 56 Braun TL, Xue AS, Maricevich RS. Differences in the management of pediatric facial trauma. Semin Plast Surg 2017; 31 (02) 118-122
• 57 McGrath A, Taylor RS. Pediatric Skull Fractures. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024. [Updated January 23, 2023]
• 58 Hogg NJ. Primary and secondary management of pediatric soft tissue injuries. Oral Maxillofac Surg Clin North Am 2012; 24 (03) 365-375